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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRrESS 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4/ f/ / / N ? y`'_ CITY/ZIP t r " L m <br /> D <br /> _ -1 <br /> CROSS STREET �1 f' � APN p <br /> PARCEL SIZE i LAND USE APPLICATION# j p <br /> OWNER NAME —�—� PHONE / M <br /> OWNER ADDRESS n � • O G CITY/STATE/ZIP <br /> CONTRACTOR /° /C / PHONE <br /> J�� /�7>�n �✓ <br /> CONTRACTOR ADDRESS ^ _ CITY/STATE/ZIP <br /> SUBCONTRACTOR /�- C� hd- ' �t�✓� PHONE 2-7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 C-61 D-09 ❑ Other NUMBER j / / ✓V EXPIRATION DATE -_ --i <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ! Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK rAew Well I Replacement Well Well Alteration/Modification Ll Other <br /> '.: Monitoring Well(s) #of wells i I Soil Boring(s) #of borings D Geotechnical #of borings <br /> 1.1 Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I>4ew Pump ❑ Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�lud Rotary ❑ Air Rotary ❑ Auger I! Cable Tool 1 I Push Point ❑ Other <br /> Proposed Well Depl:N 5(Y6 ft Excavation in diameter Open Bottom lieflravel Pack/Gravel Size in diameter <br /> Conducto asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel lastic Ij Stainless teel_ [I Other <br /> Grout Seal Depth�a ft I i Neat Cement(94 Ib bag/5-10 gal water) and Cement �� sack mix/7 gal water <br /> Be tonitefi (20%solids) I I Other <br /> Grout Placement Method) Pumped I I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By l Driller Pump Contract Other <br /> Concrete Pedestal ! Dimensions:Width ft Length ft Thick in i 1 Christy Box i I Stove Pipe <br /> PUMP 1�8ubmersible I I Turbine I I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 4 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> i, I?_ <br /> SIGNED ! 1 f TITLE O C f l ^ /� DATEni All <br /> tj <br /> ! ! 7 <br /> t J <br /> \1+\ I-_ a <br /> V � <br /> t <br /> INC UN <br /> E A R T M E N T U HEALTH E ONLY ENVIRON PR ENTAENT <br /> H D� <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By t �VI�L�O�'A1� Date c`y�+��4 I 1 SPECIAL Well Permit <br /> Pump Inspection By 'f+_At_S t d Date 1�lI ZcL� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS r L <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes I O By Cash Remitted Service Request# <br /> L <br /> Z0 <br /> EHD 43-06 3/01/16 WELL/PUMP PERMIT <br />